Provider Demographics
NPI:1639174790
Name:EATONTOWN MEDICAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:EATONTOWN MEDICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLO
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-544-9500
Mailing Address - Street 1:158 WYCKOFF RD
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-1840
Mailing Address - Country:US
Mailing Address - Phone:732-544-9500
Mailing Address - Fax:732-544-0132
Practice Address - Street 1:158 WYCKOFF RD
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1840
Practice Address - Country:US
Practice Address - Phone:732-544-9500
Practice Address - Fax:732-544-0132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04070200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ526895Medicare ID - Type UnspecifiedGROUP #